SBA Form 3503 Self-Certification for Verification of Entity Economic I

OMB Control Number 3245-0406
Expiration Date: 9/30/2020

U.S. SMALL BUSINESS ADMINISTRATION
SELF-CERTIFICATION FOR VERIFICATION OF ELIGIBLE
ENTITY FOR ECONOMIC INJURY DISASTER LOAN
You have applied for an SBA Economic Injury Disaster Loan (EIDL) that can be used for
working capital. Loan applicants seeking an economic injury loan must complete and
submit this form with the loan application.

Applicant Business Name:
Contact Person:
SBA Application Number (if known):
Federal Employer Identification Number (if applicable) or Social Security Number:
ACH Information:

Bank Name:
Routing Number:
Account Number:

SBA Form 3503 (03/20)

OMB Control Number 3245-0406
Expiration Date: 9/30/2020

The Applicant understands that SBA is relying upon this self-certification to verify that the
Applicant is an eligible entity, and the Applicant is providing this self-certification under
penalty of perjury pursuant to 28 U.S.C. 1746 for verification purposes.
ELIGIBLE ENTITY VERIFICATION
Choose One:

☐ Applicant is a business with not more than 500 employees
☐ Applicant is an agricultural e nte rprise withnot morethan500employees
☐ Applicant is an individual who operates under a sole proprietorship, with or without
employees, or as an independent contractor
☐ Applicant is a cooperative with not more than 500 employees
☐ Applicant is an Employee Stock Ownership Plan (ESOP), as defined in 15 U.S.C. 632,
with not more than 500 employees
☐ Applicant is a tribal small business concern, as described in 15 U.S.C. 657a(b)(2)(C),
with not more than 500 employees
☐ Applicant is a business, including an agricultural cooperative, aquaculture
enterprise,
nursery, or producer cooperative (but excluding all other agricultural enterprises),
with more than 500 e mploye e s that is small under SBA Size Standards located
at https://www.sba.gov/document/support--table-size-standards/
☐ Applicant is a private non-profit organization that is a non-governmental agency or
entity that currently has an effective ruling letter from the IRS granting tax
exemption under sections 501(c),(d), or (e) of the Internal Revenue Code of 1954, or
satisfactory evidence from the State that the non-revenue producing organization
or entity is a non-profit one organized or doing business under State law, or a faithbased organization.
Review and Check All of the Following:
Applicant must review and check all the following. If Applicant is not able to review and
check all the following, Applicant is not an Eligible Entity.
☐ Applicant is not engaged in any illegal activity (as defined by Federal guidelines).

SBA Form 3503 (03/20)

OMB Control Number 3245-0406
Expiration Date: 9/30/2020

☐ No principal of the Applicant with a 50 percent or greater ownership interest is more
than sixty (60) days delinquent on child support obligations.
Applicant does not present live performances of a prurient sexual nature or derive
directly or indirectly more than de minimis gross revenue through the sale of
products or services, or the presentation of any depictions or displays, of a prurient
sexual nature.
☐ Applicant does not derive more than one-third of gross annual revenue from legal
gambling activities.

I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES
THAT THE FOREGOING IS TRUE AND CORRECT.
Signature:

Date:

Name:
Title:
The estimated time for completing this portion of the application is 10 minutes. You are not required to
respond to this or any collection of information unless it displays a currently valid OMB approval
number. If you have any questions or comments concerning any aspects of this information collection,
please contact the U.S. Small Business Administration Information Branch, 409 3rd St., SW, Washington,
DC 20416 and Desk Officer for SBA, Office of Management and Budget, Office of Information and
Regulatory Affairs, New Executive Office Building , Washington, DC 20503.

SBA Form 3503 (03/20)